5/1/2009

BEFORE THE IOWA DEPARTMENT OF PUBLIC HEALTH _____________________________________________________________________ DIRECTED TO: ) [

insert case #

])[

insert full name and

)

address of subject of order

] )

FACILITY QUARANTINE ORDER

_____________________________________________________________________ The Iowa Department of Public Health (Department) has determined that you have hadcontact with a person with

Novel Influenza A H1N1

is a disease whichis spread from person to person and is associated

fever (greater than 100.0 F), cough, sorethroat, rhinorrhea (runny nose), nasal congestion, body aches, headache, chills andfatigue.

Novel Influenza A H1N1

presents a risk of serious harm to public health and if itspreads in the community severe public health consequences may result.The Department has determined that it is necessary to quarantine your movement to aspecific facility to prevent further spread of this disease. The Department has determined thatquarantine in your home and other less restrictive alternatives are not acceptable because[

insert the reason home quarantine is not acceptable, the person violated a previouslyissued home quarantine order, the person does not have an appropriate home settingconducive to home quarantine, etc.

] The Department is therefore ordering you to comply withthe following provisions during the entire period of quarantine:1.

Terms of confinement.

You are ordered to remain at the quarantine facility, _____________________ [

insert name and address of facility

], from ___________ to ____________ [

insert dates of quarantine

].2.

Requirements during confinement.

During the period of quarantine:a. You must not leave the quarantine facility at any time unless you havereceived prior written authorization from the Department to do so.b. You must not come into contact with anyone except the following persons:(i) other persons who are also under similar quarantine order at thequarantine facility;(ii) authorized healthcare providers and other staff at the quarantinefacility;(iii) authorized Department staff or other persons acting on behalf ofthe Department; and(iv) such other persons as are authorized by the Department.c. Your daily needs, including food, shelter, and medical care, will beprovided for you during the period of quarantine at the quarantine facility.You should bring clothing, toiletries, and other personal items with you tothe quarantine facility. You will have limited access to a telephone at thequarantine facility. You may bring your cell phone with you should youdesire to have greater access to a means of communication.

5/1/2009

d. You should inform your employer that you are under quarantine order andare not authorized to physically come to the work place, although you maywork from the facility via electronic or other means if appropriate. Youshould be aware that Iowa law prohibits an employer from firing,demoting, or otherwise discriminating against an employee due to thecompliance of an employee with a quarantine order issued by theDepartment. (Iowa Code section 139A.13A).3.

Information about

Novel Influenza A H1N1

You should review the informationcontained at Attachment A for information about

Novel Influenza A H1N1

. You should refer toinformation provided at the quarantine facility to address specific concerns and questions youhave about

Novel Influenza A H1N1

. In order to find out more information about

NovelInfluenza A H1N1

and its symptoms and spread, you may also access the Department

’

s web-page atwww.idph.state.ia.us.If you do not have access to the internet from the quarantinefacility, you may contact the Department at 1-800-362-2736.4.

Legal authority.

This order is issued pursuant to the legal authority contained atIowa Code chapters 135, 139A and 641 Iowa Administrative Code chapter 1, a copy of which islabeled Attachment B and is attached to this order for your review. The Department shall complywith the principles for quarantine contained in subrule 1.9(3) of this attachment when issuing andimplementing this order.5.

Ensuring compliance.

In order to ensure that you strictly comply with thisQuarantine Order the Department or persons authorized by the Department may regularlyinspect the quarantine facility.6.

Violations of order.

If you fail to comply with this Quarantine Order you may beordered to be quarantined in a more restrictive facility. In addition, failure to comply with thisorder is a simple misdemeanor for which you may be arrested, fined, and imprisoned.7.

Your rights

appeal rights.

While under quarantine you have the rights asdescribed in subrule 1.9(8) of Attachment B. In addition, you have the right to appeal this orderpursuant to subrule 1.9(7) of Attachment B. ____________________________________ ___________ DIRECTOR or MEDICAL DIRECTOR DATEIOWA DEPARTMENT OF PUBLIC HEALTHLucas State Office BuildingDes Moines, IA 50319Attachments to this Order:Attachment A -- Facts About

Novel Influenza A H1N1